The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

Attempt to deescalate the client.

Continue to observe the client for increased agitation.

Offer medications to help the client control behavior.

Ensure safety in the environment for the client and others.

Answer and Explanation

The Correct Answer is D

A.   Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B.   Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C.   While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D.   Ensuring the safety of the client and others is the priority in situations of escalating agitation.

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Correct Answer is B

Explanation

A) Incorrect. While aging can contribute to cognitive changes, it is not the primary factor in the acute onset of delirium.

B) Correct. This statement highlights the acute and rapid onset of behavioral changes, which is characteristic of delirium. Delirium is an acute confessional state characterized by alterations in cognition, attention, and level of consciousness. It often has a sudden onset.

C) Incorrect. Chronic forgetfulness may be indicative of dementia or other cognitive disorders, but it does not support the acute onset seen in delirium.

D) Incorrect. Independence and living alone do not directly relate to the acute onset of delirium.

A. Sedation and muscle stiffness B. Sweating, nausea, and diarrhea C. Mild fever, sore throat, and skin rash D. Headache, watery eyes, and runny nose

Correct Answer is A

Explanation

A) Correct. Haloperidol, a first-generation antipsychotic, commonly causes side effects like sedation (drowsiness) and extrapyramidal symptoms, including muscle stiffness.

B) Incorrect. Sweating, nausea, and diarrhea are not typically associated with haloperidol.
C) Incorrect. Mild fever, sore throat, and skin rash are not common side effects of haloperidol.
D) Incorrect. Headache, watery eyes, and runny nose are not common side effects of haloperidol.

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The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is A

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